Spray-Type Adhesion Barrier Enhances Safety and Feasibility of Robotic Repeat Liver Resection: Initial Experience and Outcomes.

Background Although various types of adhesion barriers are widely utilized in liver surgery, the safety and feasibility of their use during repeat robotic liver resection (R-RLR) are still unknown. Methods Among the 68 patients undergoing RLR with the application of the spray-type adhesion barrier at Kokura Memorial Hospital, Kitakyushu, Japan, between 2021 and 2023, 24 cases that underwent R-RLR were included in this study. The included patients were divided into two groups: those who underwent previous hepatectomy with the use of a spray-type adhesion barrier (R-RLR-B, n = 14) and those without its previous use (R-RLR-NB, n = 10). The perioperative outcomes were compared between the groups. Results There were no differences between the R-RLR-B and R-RLR-NB groups in background characteristics, difficulty scores, operative and console time, or surgical blood loss. Although no difference was found between the groups in the time required for adhesiolysis before the robotic operation, both the time required for robotic adhesiolysis (75 minutes vs. 58 minutes, p = 0.034) and total time for adhesiolysis (192 minutes vs. 141 minutes, p = 0.014) were significantly shorter in the R-RLR-B group than in the R-RLR-NB group. Otherwise, there was no conversion to open hepatectomy, no intraoperative transfusion of red blood cells, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the whole cohort. Conclusions The spray-type adhesion barrier may not be associated with an increase in the incidence of postoperative complications, including bile leakage or intraperitoneal abscess. In addition, its application during the previous hepatectomy can facilitate a secure R-RLR with reduced time for adhesiolysis. Thus, the use of the spray-type adhesion barrier for R-RLR is safe, effective, and time efficient.

An Efficient Saline-Linked Cautery (SLiC) Method for Robotic Liver Parenchymal Transection Using Simultaneous Activation of Saline-Linked Cautery and Robotic Suctioning: Detailed Technical Aspects and Short-Term Outcomes.

Introduction While there are several advantages to utilizing robotics in liver surgery compared to traditional open and laparoscopic approaches, the most challenging part of robotic liver resection (RLR) remains the liver parenchymal transection. This is primarily due to the constraints of the existing robotic tools and the absence of a standard procedure. This study presents detailed technical aspects of our novel saline-linked cautery (SLiC) method for RLR and assesses the short-term outcomes for both non-anatomical and anatomical RLRs. Methods In this study, 82 cases that underwent RLR utilizing the SLiC method at our hospital from September 2021 to December 2023 were examined. A novel SLiC method is introduced in this study for robotically transecting the liver parenchyma utilizing bipolar cautery or monopolar scissors. The technique involves activating the SLiC and robotic suctioning simultaneously. The included patients were divided into two groups: patients undergoing robotic anatomical hepatectomy (n=39), and those receiving robotic non-anatomical hepatectomy (n=43). Short-term outcomes, including intraoperative and postoperative complications, were assessed in patients receiving both anatomical and non-anatomical hepatectomies. Results In the whole cohort, 74% of patients had performance status 1 or 2, and 24% were classified as Child-Pugh class B. RLR was performed without Pringle's maneuver in more than 80% of cases in patients receiving robotic non-anatomical hepatectomy, and more than 80% of patients undergoing robotic anatomical hepatectomy required only four or fewer 15-minute Pringle's maneuvers. There was no conversion to open hepatectomy, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the entire cohort. Four postoperative complications with CDC IIIa or higher occurred (small bowel obstruction in two cases, intraabdominal hemorrhage in one, and bile leak in another), but no differences in the frequency of complications were found between those undergoing non-anatomical and anatomical hepatectomy (p=0.342). Conclusions The SLiC method, which involves simultaneously activating SLiC and robotic suctioning with either monopolar scissors or bipolar cautery, appears to be a secure and convenient technique for liver parenchymal transection in RLR. This innovative method permits precise access to the major Glissonean and venous structures within the liver, making RLR more standardized and easily applicable in routine patient care.

Successful Multimodal Treatment of Pancreatic Cancer With Extensive Superior Mesenteric Vein Thrombosis Utilizing Chemotherapy Combined With Direct Oral Anticoagulant.

It is well known that portal vein thrombosis (PVT) sometimes occurs in pancreatic cancer (PC). However, no effective treatment plan for PVT in PC patients has yet been proposed. We experienced a successfully treated case of borderline resectable pancreatic cancer (PC-BR) with extensive superior mesenteric vein thrombosis utilizing intensive chemotherapy combined with direct oral anticoagulant. The thrombus disappeared and the tumor shrank, enabling curative surgery, and long-term survival for more than five years has been achieved. We report this successful case that we experienced as an option for the treatment of PC-BR with PVT in the future era when multimodal treatment is important.

Laparoscopic Liver Resection Utilizing a Water Jet Scalpel for Patients With Liver Fibrosis.

Introduction A variety of devices are utilized in order to resect liver parenchyma in laparoscopic liver resection. However, liver fibrosis makes hepatectomy problematic because the liver is rigid and prone to bleeding. The water jet scalpel, which dissociates the liver parenchyma with a jet stream has no thermal damage and is clinically utilized in liver resection, but its safety and efficacy during laparoscopic liver resection for patients with liver fibrosis remain unknown. Methods We analyzed patients who underwent laparoscopic liver resection utilizing the water jet scalpel with liver fibrosis at our hospital. A water jet scalpel was used for liver parenchymal transection, and a saline-linked ball-tipped electrocautery was simultaneously used for hemostasis. Results Subsectionectomy was one case, left lateral sectionectomy was two cases, and non-anatomical liver resection was three cases. The median blood loss was 70 mL (24-104 mL). There was no need for the intraoperative Pringle's maneuver. No perioperative blood transfusion was performed, and there were no postoperative complications, including posthepatectomy liver failure. Conclusion It was suggested that laparoscopic liver resection in patients with liver fibrosis can be safely performed with the water jet scalpel.

Conversion to Curative Resection and Pathological Complete Response Following Targeted Therapies With Atezolizumab and Bevacizumab for Initially Unresectable Hepatocellular Carcinoma: A Case Report.

Hepatocellular carcinoma is a malignancy with an increasing incidence worldwide and is one of the most serious cancers in adults. We encountered a case of initially unresectable massive hepatocellular carcinoma in which conversion to curative resection and pathological complete response were achieved after atezolizumab plus bevacizumab therapy. Atezolizumab plus bevacizumab combination chemotherapy may be one of the most promising options for unresectable hepatocellular carcinoma.

Massive Retroperitoneal Hematoma After Inguinal Hernia Repair Using Prolene® Hernia System: A Case Report.

Retroperitoneal hematoma is a possibly fatal condition that is frequently observed as a complication of procedures such as femoral artery catheterizations. We currently present a case of massive retroperitoneal hematoma after inguinal hernioplasty using Prolene® Hernia System mesh in a warfarin-treated patient. Especially in the case of inguinal hernioplasty in a patient receiving warfarin therapy, surgeons must pay close attention to prevent hemorrhage from the preperitoneal space, or they may opt for a different technique, such as the Lichtenstein method or laparoscopic approach.

An Efficient Method of Hepatoduodenal Ligament Taping for Pringle's Maneuver During Robotic Liver Resection.

Background and objective Pringle's maneuver is often applied to reduce bleeding during liver resection (LR), although the taping of the hepatoduodenal ligament (HL) is challenging and dangerous due to the lack of tactile perception in robotic liver resection (RLR). In this study, we describe a secure and easy HL taping method in RLR. Methods Twenty-seven cases that underwent RLR at our institution from April to November 2022 were examined. For the HL taping, a taping tool was prepared with a flexible catheter and 3 mm-thick silicon tape. The lesser omentum was opened, the taping tool was inserted behind the HL, and the HL was encircled by silicon tape. The length of time required for taping and the number of attempts were measured. Intraoperative blood loss, the occurrence of post-hepatectomy liver failure (PHLF), and complications were examined. Results A total of 18 cases were analyzed, after excluding cases in which taping was not attempted due to adhesion from repeated hepatectomy. The median time taken for taping was 55 seconds (range: 11-162 seconds), and the median number of attempts for taping was one (range: 1-4). No accidental injury was observed during the procedure. Intraoperative blood loss was 24 mL (range: 5-400). No PHLF occurred, and complications occurred in two cases (one case of bile leakage and one case of pulmonary atelectasis). Conclusion Based on our findings, our method enables secure and time-efficient HL taping in RLR.

The Impact of Modified Two-Surgeon Technique for Laparoscopic Liver Resection on the Training of Surgeons-in-Training.

Introduction Although laparoscopic liver resection (LLR) has gained widespread acceptance over the last decade, it is associated with a much steeper learning curve than other laparoscopic procedures. We currently perform a modified two-surgeon technique for LLR. We assessed the effect of our LLR technique on the surgical outcome and the learning curve of surgeons-in-training when pure non-anatomical LLR was performed. Methods Between 2017 and 2021, 118 LLRs were conducted at our institution, 42 of which were pure non-anatomical LLRs performed by five surgeons-in-training (with a career of 6-13 years). The perioperative outcomes of these cases were compared to those performed by the board-certified attending surgeon. Regarding the learning curve of surgeons-in-training, the duration of operation was used as an index of the proficiency level, and the number of surgical cases in which the surgeons reached the median duration of operation was examined. Results Mortality was zero, and neither postoperative bleeding nor bile leak was experienced in the whole cohort. There were no differences between surgeons-in-training and the board-certified surgeon in the duration of the operation, intraoperative blood loss, rate of postoperative complications, or length of postoperative stay (LOS). Among the operations performed by five surgeons-in-training, the rate of LLR with a difficulty score of 4 or higher was 52% (30%-75%). Concerning the learning curve, all five surgeons-in-training gradually shortened the duration of operation for each additional case and reached the median duration (218 minutes) by experiencing a median of five cases (3-8 cases). Conclusion A modified two-surgeon technique during LLR is feasible, with a relatively low number of cases (five cases) required to shorten the duration of operation in non-anatomical LLR. This technique is safe and beneficial to the education of surgeons-in-training.

Intrahepatic Glissonean Approach for Robotic Anatomical Liver Resection of Segment 7 Using the Saline-Linked Monopolar Cautery Scissors (SLiC-Scissors) Method: A Technical Case Report With Videos.

Anatomical hepatectomy of segment 7 (S7) is technically difficult due to its difficult accessibility. Here, we present our experience of robotic anatomical S7 subsectionectomy of the liver employing the saline-linked cautery scissors (SLiC-Scissors) technique. After the right lobe was fully mobilized, dissection of the Glissonean pedicle and hepatic venous branch of S7, as well as the liver parenchymal transection, were safely performed using the SLiC-Scissors method. Despite its technological complexity, the intrahepatic Glissonean approach for robotic anatomical S7 subsectionectomy of the liver employing the SLiC scissors method is safe and efficient.

Long-Term Oncological Control by Repeated Minimally Invasive Hepatectomy for Intrahepatic Cholangiocarcinoma Exhibiting Atypical Marker Expression of CK7-CK20+: A Case Report.

There are few reports of repeated liver resections being performed multiple times for intrahepatic recurrence of intrahepatic cholangiocarcinoma (ICC). We performed five minimally invasive liver resections and two minimally invasive lung resections for ICC with metachronous intrahepatic recurrence and lung metastases. Pathological examination revealed that all resected tumors were moderately differentiated mass-forming ICC with immunohistochemical marker expression of CK7 negative and CK20 positive. We present this as a rare case of ICC with atypical marker expression in which long-term tumor control was achieved with multiple minimally invasive liver resections over 47 months from the initial diagnosis.

Novel Liver Parenchymal Transection Technique Using Saline-linked Monopolar Cautery Scissors (SLiC-Scissors) in Robotic Liver Resection.

Introduction Although there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method. Methods We present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique. Results Six of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality. Conclusions The SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.

Inhibition of NLRP3 inflammasome by MCC950 improves the metabolic outcome of islet transplantation by suppressing IL-1ß and islet cellular death.

Early rejection is a critical issue to be overcome to achieve successful islet transplantation. NLRP3 inflammasome is a protein complex that mediates the maturation of pro-interleukin (IL)-1ß and pro-IL-18 to IL-1ß and IL-18, respectively, which induce cellular death. Here, we investigated the impact of NLRP3 inflammasome and the effect of its inhibition by MCC950 in a rodent model of islet transplantation. We assessed the therapeutic effects of MCC950, a specific inhibitor of NLRP3 inflammasome, on gene expression, islet survival ratio and viability, and islet transplantation in mice. NLRP3 inflammasome-related gene (Nlrp3 and Il1b) expression was upregulated in islets stimulated with proinflammatory cytokines and suppressed when incubated with MCC950. Survival ratio and viability of incubated islets were reduced by cytokine stimulation and improved by MCC950. Regarding islet transplantation, the number of apoptotic cells in transplanted islets was reduced by MCC950. Furthermore, the expression of IL-1ß in transplanted islets, migration of macrophages around islets, and fluctuation of blood glucose levels were suppressed by MCC950. Our study revealed that NLRP3 inflammasome worsened the therapeutic outcomes of islet transplantation and that MCC950 administration improved glycaemic control in syngeneic mice that underwent islet transplantation by inhibiting inflammation, which suppressed islet death.

Evaluation of vascular pain in patients with colorectal cancer receiving peripheral venous chemotherapy with or without oxaliplatin.

Oxaliplatin is a key chemotherapy drug in patients with colorectal cancer. Administration of oxaliplatin via a peripheral vein often causes vascular pain. However, no studies have evaluated vascular pain in patients with colorectal cancer in relation to peripheral venous administration of chemotherapy with or without oxaliplatin. We evaluated oxaliplatin-induced vascular pain using subjective and objective methods. We determined if oxaliplatin induced vascular pain in patients with colorectal cancer using a Visual Analog Scale (VAS) and a PainVision PS-2100 device. We compared VAS score between chemotherapy regimens with or without oxaliplatin, and between genders. We also examined the correlations of VAS score with pain intensity examined by the PainVision PS-2100, and with age and vessel diameter. A total of 98 patients with colorectal cancer were enrolled in this study, including 78 patients who received oxaliplatin via peripheral venous administration and 20 who received chemotherapy without oxaliplatin. The median VAS scores in patients with and without oxaliplatin were 36.5 (interquartile range 9.0-60.0) and 0 (0-4.0), respectively (P < 0.001), and the median pain intensities according to PainVision were 43.5 (14.3-98) and 36.5 (9.3-58.5), respectively (P < 0.001). There was a positive correlation between VAS and pain intensity (r = 0.584), but no correlation between VAS score and age (r = -0.174) or vessel diameter (r = -0.107). Peripheral venous administration of oxaliplatin induced vascular pain, measured both subjectively and objectively, in patients with colorectal cancer, regardless of vessel diameter.

The Relationship Between Evaluation Methods for Chemotherapy-Induced Peripheral Neuropathy.

Numbness and pain are currently evaluated using subjective methods such as the visual analogue scale (VAS). PainVision (PV) is an analytical instrument that was designed to quantitatively assess sense perception and nociception in patients. Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most important adverse events that renders prolonged chemotherapy difficult. To assess the features of CIPN, we aimed to compare PV methods with existing methods. A total of 73 patients received oxaliplatin for metastatic colorectal cancer. Registered patients included 37 men and 36 women in the range of 37 to 89 years (median 70). CIPN was evaluated a total of 483 times (median per patient six times). Our study examined the correlation between evaluation methods of CIPN using VAS and PV, respectively. The average VAS (hand), VAS (foot) and PV scores of CIPN were 18.4 (range: 0-100), 23.8 (range: 0-100), and 24.7 (range: 0-496), respectively. VAS (hand), VAS (foot), and FACT/GOG-NTX (NTX2, NTX4 and NTX8) were significantly correlated with PV. PV showed no correlation with a Disk-Criminator or the monofilament test used as a quantitative evaluation. The evaluation of CIPN is complex, and further improvement is required for evaluation with PV.

Objective evaluation of oxaliplatin-induced vascular pain secondary to peripheral vein administration.

BACKGROUND: During oxaliplatin chemotherapy administration via a peripheral vein, vascular pain requires changing of the intravenous infusion route on occasion. Vascular pain induced by anticancer drugs reduces the rate of patient continuation and completion of chemotherapy. Pain is presently appraised using subjective methods, such as the visual analog scale (VAS). However, because pain evaluation can vary depending on the physical state and mood of the patient at the time of assessment, it is desirable to evaluate pain objectively. PainVision PS-2100 (PV) is a medical device that was designed to objectively and quantitatively assess patient nociception and perception. METHODS: The present study examined the correlation of subjective and objective assessment of oxaliplatin-induced vascular pain using VAS and PV, respectively. RESULTS: Vascular pain was assessed using both PV and VAS a total of 173 times for 58 colorectal cancer patients. Partial correlation analysis was performed to evaluate the relationship between PV and VAS. The mean PV and VAS scores were 44.5 (range: 0-596) and 24.8 (range: 0-100), respectively. The partial correlation coefficient was 0.408 (p < 0.0001). CONCLUSIONS: A strong correlation was not observed between the results, and a weak correlation was observed between VAS and PV scores. Objective evaluation of oxaliplatin-induced vascular pain will be required to help patients overcome vascular pain.

Subjective and objective assessment of oxaliplatin-induced peripheral neuropathy.

Numbness and pain are currently evaluated using subjective methods such as the visual analog scale (VAS). However, because assessment of pain can vary greatly depending on the mood and physical state of the patient at the time of assessment, it is best to evaluate pain objectively. pain vision PS-2100 (PV) is an analytical instrument that was designed to quantitatively and objectively assess sense perception and nociception in patients. The present study examined the correlation of subjective and objective assessment of oxaliplatin-induced peripheral neuropathy (PN) using VAS and PV, respectively. The mean VAS and PV scores of PN were 20.5 (range 0-100) and 27.9 (range 0-416), respectively. The partial correlation coefficient was 0.274 (p = 0.0003). No strong correlation was observed between the results and a weak correlation was observed between VAS and PV.

[Pathways from initial symptoms to psychiatric treatment in patients with schizophrenia].

Early intervention is essential for improving the long-term prognosis of schizophrenic patients. With the objective of contributing to early treatment in communities in the future, we retrospectively investigated patient data, including the pathway to psychiatric care, the course prior to consultation, and initial symptoms. An interview survey was conducted involving a total of 125 patients receiving treatment for a diagnosis of schizophrenia and 74 family members using two questionnaire sheets to collect data on the pathway to psychiatric care, age at onset, time between onset and the initiation of treatment, initial symptoms, and the necessary information. For the pathway to psychiatric care, facilities were classified into : psychiatric clinic, psychiatric hospital, psychiatric department of a general hospital, and general practices, and tendencies were investigated. As for the initial symptoms, differences between those recognized by the patients themselves and their families were investigated. The results showed that approximately 80% of patients had first visited medical facilities, while the remaining patients had consulted psychologists, school nurses, teachers, or public health centers. The mean time from onset to initial psychiatric consultation was 24.7 ± 3.3 months, with a median period of 6.0 months. This duration was particularly long among patients who first visited general practitioners. As the initial symptoms, 70% of patients had psychiatric symptoms as subjective symptoms, and more than 70% of family members equally noticed psychiatric symptoms. On the other hand, 40% of patients had positive symptoms, but only 20% of family members had noticed the positive symptoms. A total of 30% of patients had been aware of somatic symptoms, and these patients were significantly more likely to initially visit physicians in a department other than the psychiatric department. As for delay in consultation, patients who had onsets at an early age tended to take longer to make the initial visit. The above findings confirmed the necessity of disease education at schools, given that onset can occur in school-age children, as well as the establishment of a mental health network, understanding of psychiatric diseases among primary care physicians and their cooperation with psychiatrists, and increased public awareness regarding psychiatric diseases.

[Large bowel malignant obstruction treated with SEMS placement as a bridge to surgery procedure].

We treated 5 cases of preoperative decompression using the self-expandable metallic stent (SEMS) against obstructive left side colon cancer since October 2013. The obstruction site was the descending colon in one patient, sigmoid colon in 2, rectal-sigmoid colon in 1, and rectum in 1. Colonic stent placements were successful in all cases. Oral intake started an average of 3.7 days after SEMS placement. All patients underwent radical surgery an average of 17.2 days after SEMS placement. Two patients waited for surgery while out of the hospital. All patients underwent colonoscopy. One patient had advanced colon cancer. Our findings show that SEMS placement can treat obstructive left-sided colon cancer.

[A case of delayed subcutaneous metastases of gastric carcinoma effectively treated with S-1 plus cisplatin chemotherapy].

We encountered a case of delayed subcutaneous metastases of gastric carcinoma. The patient underwent distal gastrectomy for advanced gastric carcinoma 11 years ago. Postoperative pathological diagnosis indicated stage IIIB disease, poorly differentiated adenocarcinoma (scirrhous, T4a, ly2, v2, N2, H0, P0). Three courses of adjuvant chemotherapy with 5-fluorouracil (5-FU)+cisplatin (CDDP) were administered; however, the patient discontinued the treatment. No signs of recurrence were observed for 11 years after the treatment. However, subcutaneous metastases in the front portion of the head and the back and an ovarian tumor were detected after the remission period. The specimen from the resected subcutaneous tumor from the back indicated signet-ring cell carcinoma, and delayed subcutaneous and ovarian metastases of the gastric carcinoma was diagnosed. Therefore, 8 courses of the S-1+CDDP combination therapy were administered. The cutaneous metastases disappeared, but the ovarian tumor progressed and was therefore resected. Analysis of the resected ovarian tumor also indicated signet-ring cell carcinoma. We report a case of delayed recurrence of gastric carcinoma that was effectively treated with chemotherapy.